Elliot Krane: The mystery of chronic pain

Prevoditelj: Jelena Horvat Recezent: Veronika Rasic

I'm a pediatrician and an anesthesiologist,

Pedijatar sam i anesteziolog,

so I put children to sleep for a living.

dakle, zarađujem za život stavljajući djecu na spavanje.

(Laughter)

(Smijeh)

And I'm an academic, so I put audiences to sleep for free.

Ja sam i akademik, dakle publiku uspavljujem besplatno.

(Laughter)

(Smijeh)

But what I actually mostly do

No ono čime se najviše bavim

is I manage the pain management service

je da vodim odjel za upravljanje bolom

at the Packard Children's Hospital up at Stanford in Palo Alto.

u Packard dječjoj bolnici kod Stanforda u Palo Altu.

And it's from the experience

Iz iskustva

from about 20 or 25 years of doing that

dugog 20 ili 25 godina, koliko se već time bavim,

that I want to bring to you the message this morning,

ovog vam jutra želim prenijeti poruku

that pain is a disease.

da je bol zapravo bolest.

Now most of the time,

Sada većinu vremena

you think of pain as a symptom of a disease,

mislite o bolu kao simptomu bolesti.

and that's true most of the time.

To je uglavnom točno.

It's the symptom of a tumor or an infection

Ona je simptom tumora ili infekcije,

or an inflammation or an operation.

ili upale, ili operacije.

But about 10 percent of the time,

No oko 10 posto vremena

after the patient has recovered from one of those events,

nakon što se pacijent oporavio od nekog od navedenih događaja

pain persists.

bol ne popušta.

It persists for months

Ustraje mjesecima

and oftentimes for years,

a vrlo često i godinama.

and when that happens,

A kad se to dogodi,

it is its own disease.

ono postaje bolest sama za sebe.

And before I tell you about how it is that we think that happens

I prije nego što vam kažem kako mislimo da se to događa

and what we can do about it,

i što možemo u vezi toga učiniti

I want to show you how it feels for my patients.

želim vam pokazati kako se osjećaju moji pacijenti.

So imagine, if you will,

Zamislite, ako želite

that I'm stroking your arm with this feather,

da vam milujem ruku ovim perom

as I'm stroking my arm right now.

kao što to upravo činim

Now, I want you to imagine

Sada želim da zamislite

that I'm stroking it with this.

da je milujem ovim.

Please keep your seat.

Molim vas ostanite na mjestu.

(Laughter)

(Smijeh)

A very different feeling.

Prilično drugačiji osjećaj.

Now what does it have to do with chronic pain?

No kakve to veze ima s kronično boli?

Imagine, if you will, these two ideas together.

Zamislite, ako želite, ove dvije ideje zajedno.

Imagine what your life would be like

Zamislite kakav bi vam život bio

if I were to stroke it with this feather,

da vas milujem ovim perom,

but your brain was telling you

ali vaš vam mozak govori

that this is what you are feeling --

da je ovo ono što osjećate --

and that is the experience of my patients with chronic pain.

i upravo je to ono što osjećaju moji pacijenti.

In fact, imagine something even worse.

Zamislite zapravo štogod još gore.

Imagine I were to stroke your child's arm with this feather,

Zamislite da milujem dječju ruku ovim perom.

and their brain [was] telling them

a njihov mozak im govori

that they were feeling this hot torch.

da osjećaju ovu vruću baklju.

That was the experience of my patient, Chandler,

Takvo je bilo iskustvo moje pacijentice, Chandler,

whom you see in the photograph.

koju vidite na fotografiji.

As you can see, she's a beautiful, young woman.

I kao što možete vidjeti ona je lijepa, mlada žena.

She was 16 years old last year when I met her,

Imala je 16 godina prošle godine kad sam je upoznao,

and she aspired to be a professional dancer.

željela je postati profesionalna plesačica.

And during the course of one of her dance rehearsals,

I tijekom jedne od plesnih proba

she fell on her outstretched arm and sprained her wrist.

pala je na ispruženu ruku i uganula zglob.

Now you would probably imagine, as she did,

Vjerojatno biste pomislili, kao što je i ona,

that a wrist sprain is a trivial event

da je uganuće zgloba trivijalan događaj

in a person's life.

u životu svake osobe.

Wrap it in an ACE bandage,

Učvrstite zglob elastičnim zavojem

take some ibuprofen for a week or two,

uzimajte ibuprofen tjedan ili dva

and that's the end of the story.

i to je kraj priče.

But in Chandler's case, that was the beginning of the story.

No u Chandlerinom slučaju bio je to tek početak priče.

This is what her arm looked like

Ovako je izgledala njena ruka

when she came to my clinic about three months after her sprain.

kad je došla u moju kliniku tri mjeseca nakon uganuća.

You can see that the arm is discolored,

Možete vidjeti da je ruka obezbojena,

purplish in color.

purpurne boje.

It was cadaverically cold to the touch.

Bila je mrtvački hladna na dodir.

The muscles were frozen, paralyzed --

Mišići su bili smrznuti, paralizirani --

dystonic is how we refer to that.

distonija je kako to nazivamo.

The pain had spread from her wrist to her hands,

Bol se proširio sa zgloba na ruku

to her fingertips, from her wrist up to her elbow,

do prstiju, od zgloba do lakta

almost all the way to her shoulder.

gotovo sve do ramena.

But the worst part was,

Ali najgori dio nije bio

not the spontaneous pain that was there 24 hours a day.

spontana bol koji je trajala 24 sata na dan.

The worst part was that she had allodynia,

Najgori dio bio je da je imala alodiniju,

the medical term for the phenomenon that I just illustrated

medicinski termin za fenomen koji sam upravo ilustrirao

with the feather and with the torch.

s perom i s bakljom.

The lightest touch of her arm --

Najlakši dodir na njenoj ruci --

the touch of a hand,

dodir ruke,

the touch even of a sleeve, of a garment, as she put it on --

čak dodir rukava, odjeće, koju je nosila --

caused excruciating, burning pain.

uzrokovao je iznimno jake, goruće bolove.

How can the nervous system get this so wrong?

Kako može živčani sustav tako pogriješiti?

How can the nervous system

Kako živčani sustav može

misinterpret an innocent sensation

pogrešno interpretirati nevini osjećaj

like the touch of a hand

kao što je to dodir ruke

and turn it into the malevolent sensation

i pretvoriti ga u zlonamjeran osjećaj

of the touch of the flame?

dodira baklje.

Well you probably imagine that the nervous system in the body

Pa vjerojatno zamišljate da je živčani sustav u tijelu

is hardwired like your house.

umrežen kao što je to vaša kuća.

In your house, wires run in the wall,

U vašoj kući žice idu u zid,

from the light switch to a junction box in the ceiling

od prekidača do razvodne kutije u stropu

and from the junction box to the light bulb.

i od razvodne kutije do žarulje.

And when you turn the switch on, the light goes on.

I kad pritisnete prekidač, upali se svjetlo.

And when you turn the switch off, the light goes off.

I kad ga opet pritisnete, svjetlo se gasi.

So people imagine the nervous system is just like that.

Ljudi zamišljaju da je i živčani sustav upravo takav.

If you hit your thumb with a hammer,

Ako se udarite čekićem po palcu,

these wires in your arm -- that, of course, we call nerves --

te žice u vašoj ruci -- koje, naravno, zovemo živci --

transmit the information into the junction box in the spinal cord

prenose informaciju do razvodne kutije

where new wires, new nerves,

gdje nove žice, novi živci,

take the information up to the brain

prenose informaciju do mozga

where you become consciously aware that your thumb is now hurt.

gdje postajete svjesni da je palac ozlijeđen.

But the situation, of course, in the human body

No situacija, naravno, u ljudskom tijelu

is far more complicated than that.

je mnogo kompliciranija od toga.

Instead of it being the case

Umjesto toga

that that junction box in the spinal cord

da je razvodna kutija u leđnoj moždini

is just simple where one nerve connects with the next nerve

samo jednostavno mjesto gdje se jedan živac povezuje s drugim

by releasing these little brown packets

oslobađanjem malih smeđih paketa

of chemical information called neurotransmitters

kemijskih informacija zvanih neurotransmiteri

in a linear one-on-one fashion,

na linearan jedan na jedan način,

in fact, what happens

ono što se zapravo događa

is the neurotransmitters spill out in three dimensions --

je da se neurotransmiteri prospu u tri dimenzije --

laterally, vertically, up and down in the spinal cord --

bočno, okomito, gore i dolje u leđnoj moždini --

and they start interacting

i počnu međudjelovati

with other adjacent cells.

s drugim susjednim stanicama.

These cells, called glial cells,

Te stanice, zvane glijalne stanice,

were once thought to be

nekoć su se smatrale

unimportant structural elements of the spinal cord

nevažnim strukturnim elementima leđne moždine

that did nothing more than hold all the important things together,

koji ne rade ništa drugo nego drže važne stvari zajedno,

like the nerves.

kao što su živci.

But it turns out

No ispada

the glial cells have a vital role

da glijalne stanice imaju vitalnu ulogu

in the modulation, amplification

u modulaciji, pojačavanju

and, in the case of pain, the distortion

i, u slučaju bola, iskrivljenju

of sensory experiences.

osjetilnih iskustava.

These glial cells become activated.

Te se glijalne stanice aktiviraju.

Their DNA starts to synthesize new proteins,

Njihov DNA počinje sintetizirati nove proteine,

which spill out

koji se prospu

and interact with adjacent nerves,

i reagiraju s susjednim živcima.

and they start releasing their neurotransmitters,

I oni počinju oslobađati njihove neurotransmitere.

and those neurotransmitters spill out

I ti neurotransmiteri se prospu

and activate adjacent glial cells, and so on and so forth,

i aktiviraju susjedne glijalne stanice, i tako dalje, i dalje,

until what we have

sve dok ne nastane

is a positive feedback loop.

pozitivnu povratnu petlju.

It's almost as if somebody came into your home

To je otprilike kao kad bi netko ušao u vašu kuću

and rewired your walls

i ponovno postavio žice u zidovima

so that the next time you turned on the light switch,

i to tako da se kad sljedeći put upalite svjetlo

the toilet flushed three doors down,

ispere toalet tri vrata niže

or your dishwasher went on,

ili da se upali stroj za pranje suđa,

or your computer monitor turned off.

ili ugasi kompjuterski monitor.

That's crazy,

To je suludo,

but that's, in fact, what happens

ali to je upravo ono što se događa

with chronic pain.

s kroničnom boli.

And that's why pain becomes its own disease.

I zbog toga bol postaje bolest sama po sebi.

The nervous system has plasticity.

Živčani sustav je plastičan.

It changes, and it morphs

Mijenja se i oblikuje se

in response to stimuli.

kao odgovor na podražaj.

Well, what do we do about that?

Dobro, što ćemo učiniti u vezi toga?

What can we do in a case like Chandler's?

Što možemo učiniti u slučaju kao što je Chandlerin?

We treat these patients in a rather crude fashion

Liječimo te bolesnike na prilično sirov način

at this point in time.

u ovom trenutku.

We treat them with symptom-modifying drugs --

Liječimo ih lijekovima koji uklanjaju simptome --

painkillers --

lijekovima protiv bolova --

which are, frankly, not very effective

koji, iskreno, nisu veoma učinkoviti

for this kind of pain.

za ovu vrstu boli.

We take nerves that are noisy and active

Uzimamo živce koji su bučni i aktivni,

that should be quiet,

a trebali bi biti mirni,

and we put them to sleep with local anesthetics.

i uspavljujemo ih lokalnom anestezijom.

And most importantly, what we do

I najvažnije što radimo

is we use a rigorous, and often uncomfortable, process

je da koristimo krut, i često neugodan, proces

of physical therapy and occupational therapy

fizikalne i radne terapije

to retrain the nerves in the nervous system

da bismo naučilii živce u živčanom sustavu

to respond normally

da odgovaraju normalno

to the activities and sensory experiences

na aktivnosti i osjetilna iskustva

that are part of everyday life.

koja su dio svakodnevice.

And we support all of that

I sve to podržavamo

with an intensive psychotherapy program

intenzivnim programom psihoterapije

to address the despondency, despair and depression

zbog malodušnosti, očaja i depresije

that always accompanies

koji uvijek prate

severe, chronic pain.

jaku, kroničnu bol.

It's successful,

To je uspješno,

as you can see from this video of Chandler,

kao što možete vidjeti na ovom Chandlerinom videu

who, two months after we first met her,

koja dva mjeseca nakon našeg prvog susreta,

is now doings a back flip.

sada izvodi kolut unazad.

And I had lunch with her yesterday

Ručao sam s njom jučer

because she's a college student studying dance at Long Beach here,

zato jer studira ples ovdje na Long Beachu.

and she's doing absolutely fantastic.

I izvrsno se osjeća.

But the future is actually even brighter.

Budućnost je zapravo još svjetlija.

The future holds the promise

Budućnost nam pruža nadu

that new drugs will be developed

da će biti otkriveni novi lijekovi

that are not symptom-modifying drugs

koje neće uklanjati samo simptome

that simply mask the problem,

koji jednostavno maskiraju problem.

as we have now,

kao što imamo sada,

but that will be disease-modifying drugs

nego da će postojati lijekovi koji uklanjaju bolest

that will actually go right to the root of the problem

koji će zapravo ići do korijena problema

and attack those glial cells,

i napasti te glijalne stanice

or those pernicious proteins

ili štetne proteine

that the glial cells elaborate,

koje stvaraju glijalne stanice,

that spill over and cause this central nervous system wind-up,

koje se prospu i uzrokuju paralizu središnjeg živčanog sustava,

or plasticity,

ili plastičnost,

that so is capable

koja može

of distorting and amplifying

iskriviti i pojačati

the sensory experience that we call pain.

osjetilno iskustvo koje nazivamo bol.

So I have hope

Pa se nadam

that in the future,

da će ubuduće

the prophetic words of George Carlin will be realized,

proročanske riječi Georga Carlina biti ostvarene.

who said, "My philosophy:

koji je rekao: "Moja filozofija?

No pain, no pain."

Bez boli, bez boli.

Thank you very much.

Mnogo vam hvala.

(Applause)

(Pljesak)